Jun 20, 1992 - Compulsory admission of dangerous psychopaths. Psychiatrists are damned if they do and damned if they don't. Few psychiatrists outside the ...
LONDON, SATURDAY 20 JUNE 1992
Compulsory admission of dangerous psychopaths Psychiatrists are damned ifthey do and damned ifthey don't Few psychiatrists outside the special hospitals readily take responsibility for compulsorily detained psychopaths. About a quarter of the patients in special hospitals are detained under the legal category psychopathic disorder,' but the proportion drops to a mere 0.24% among patients compulsorily admitted to ordinary NHS facilities in England and Wales.2 Indeed, the very diagnosis of psychopathy or personality disorder is sometimes given by psychiatrists as a reason to reject mentally abnormal offenders for admission to their wards from the courts.3 Unsurprisingly, therefore, few psychiatrists now have the skills adequately to diagnose, manage, and treat patients with severe personality disorders. Furthermore, virtually no large research projects have been undertaken in the United Kingdom for many years. Meanwhile, it has also become increasingly difficult to contain inpatient psychopaths as district health authorities have progressively abandoned locked facilities, dismantled structured regimens that could have provided long term care, and embraced an increasingly restrictive policy of care in the community. Many psychiatrists simply do not see themselves as having any role in the compulsory admission of psychopaths. This view is not entirely shared by other professions or the public. Probation officers, prison staff, and the police frequently complain that they have to shoulder the burden of a group of people who seem to them to be clearly mentally disordered but whom psychiatrists will not admit. A recent series of highly publicised escapes from secure hospitals,45 homicides committed soon after discharge,6 and other disasters involving dangerous patients7 have increased the public's awareness of the risks to safety. Concern is now being expressed that the Mental Health Act may not adequately protect the public from dangerous psychopaths.8 Being denied admission to hospital after being deemed "untreatable" by a psychiatrist is sometimes followed by further serious offences.' Is there a genuine case for hospital treatment and supervision in the community for dangerous psychopaths? The answer is not straightforward. Account must be taken of both the shortage of appropriate resources and the fact that many patients with severe personality disorder do not show much sustained response to conventional psychiatric treatments. Nevertheless, patients with personality disorder are still informally admitted to hospital despite the reluctance of their psychiatrists, often in crises after deliberate self harm, substance misuse, and other impulsive behaviours, BMJ
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Recent research has shown that many such patients are exceptionally prone to recurrent episodes of serious mental disorder over their lifetime.'0 These treatable conditions will inevitably place a high demand on psychiatric services even if the underlying abnormality ultimately remains unresponsive. But inpatient treatment of psychopaths is notoriously difficult and can be physically and emotionally hazardous to the staff concerned. An ability to split staff teams" and induce profound countertransference reactions'2 is well known. For those who attempt to manage the most difficult and dangerous cases the price may be too high. In Scotland the murders committed by two psychopaths who had escaped from State Hospital, Carstairs,'3 led to a total collapse of staff morale and the locking out of the physician superintendent. Because psychopaths have a higher risk of reoffending than other patients when released from hospital""'6 psychiatrists must be wary of accepting more responsibility than can realistically be taken and should not admit them to inpatient facilities inadequate for safe management. Although research suggests that some are helped by inpatient psychiatric treatment,'7'8 doctors who retain any interest in this problem may be taking a serious risk with their reputation if therapeutic success is measured only in terms of reoffending behaviour after discharge. Official inquiries in two regional secure units after homicides had been committed by psychopaths on trial leave have done little to rekindle enthusiasm at a medium level of security. Some consultants in these units have questioned their relationship with the special hospitals and responsibilities for rehabilitating patients whose original admission into maximum security had nothing to do with them. Suspensions of general psychiatrists whose psychotic patients killed during admission or after discharge from open wards have sent shock waves through the profession and do not encourage others to take responsibilities for an even higher risk group of patients. In this context the enthusiasm of the Reed Committee for diverting mentally abnormal offenders (including psychopaths) from the criminal justice to the health care system'9 may well founder if the price of professional responsibility for dangerous patients remains too high. The failure of some regional health authorities to implement the recommendations of the Butler Committee20 and provide adequate services for difficult and offender patients is just part of the dilemma of managing psychopaths within the NHS. Stagnation could well follow Reed's excellent reports2' as it did Butler's unless 1581
several deficiencies are addressed. A few additional specialist facilities might be developed both in prisons and in hospitals to promote research and training. But it would be a brave psychiatrist outside the special hospitals who took on the responsibility for a specialist unit for psychopaths in the current climate. The Mental Health Act 1983 places responsibilities on psychiatrists that in many cases cannot be fulfilled. Psychiatrists and patients may be caught in a dilemma whereby no one wishes to take responsibility for an unacceptable risk. If proposals such as increased use of transfer of psychopaths to hospital under section 47 of the Mental Health Act22 are to take place then the covert political pressures to continue to detain those who are dangerous after the expected dates of their release must be removed. An alternative to detention in hospital without time limit when no effective treatment can be given but the patient remains potentially dangerous will also have to be found for psychopaths, possibly by using determinate sentences for treatment as in the Netherlands. Most importantly, psychiatrists will need to inform other professionals, the media, and ultimately the public about what can realistically be achieved with treatment and that psychiatric hospitals are no longer places that can provide long term custodial care. It is paradoxical that other professionals such as probation officers and members of the Parole Board accept that a proportion of their clients will reoffend and that these reoffenders do not risk widespread public opprobrium or reflex disciplinary measures. Psychiatrists in general, and forensic psychiatrists in particular, find themselves increasingly being expected to deliver the impossible- 100% safety, which no treatment in medicine can claim. They will therefore be obliged to practise increasingly defensively. Unless the current problems of inadequate service provision, lack of research and training, irrelevant mental health legislation, and unrealistic public expectations of the power of
psychiatry are addressed little progress will be made in improving the care of psychopaths and indeed many other potentially dangerous patients. Meanwhile, the disasters, inquiries, and suspensions will continue. JEREMY W COID
Senior Lecturer in Forensic Psychiatry, Department of Psychological Medicine, St Bartholomew's Hospital, London EClA 7BE
CHRISTOPHER CORDESS Consultant Forensic Psychiatrist, North West Thames Forensic Psychiatry Service, London WI I 2PS 1 Hamilton J. Special hospitals and the state hospital. In: Bluglass R, Bowden P, eds. Principals and practice offorensic psychiatry. Edinburgh: Churchill Livingstone, 1990:1363-73. 2 Government Statistical Service. In-patients formally detained in hospitals under the Mental Health Act 1983 and other legislations, England, 1984-1988/9. Statistical Bulletin 1991;2:91. 3 Coid JW. Mentally abnormal offenders on remand. I. Rejected or accepted by the NHS? II. Comparison of services provided by Oxford and Wessex regions. BMJ7 1988;2%;1779-84. 4 Police arrest man after Broadmoor escape. Independent 1991 July 23. 5 Broadmoor sex assault man escapes on day trip. Independent 1991 Oct 18. 6 Psychopath killed girl after release. Independent 1991 Oct 3. 7 Psychiatrists to lead inquiry into killings. Independent 1991 Oct 4. 8 Pilkington E. Fear on the streets. Guardian 1992 Feb 5:19. 9 Sex attacker who killed girl gets life. Independent 1991 Dec 7. 10 Coid JW. DSM-III diagnosis in criminal psychopaths; a way forward. Criminal Behaviour and Mental Health (in press). 11 Strasburger L. The treatment ofantisocial syndromes: the therapist's feelings. In: Reid W, Dorr D, Walker J, Bonner J, eds. Unmasking the psychopath. New York: Norton, 1986:191-207. 12 Symington N. The response aroused by the psychopath. International Revie of Psychoanalysis 1980;7:291-8. 13 Scottish Home and Health Department. Report of a public local inquiry into circumstances surrounding the escape of two patients on 30th November 1976 and into security and other arrangements at the hospital. Edinburgh: HMSO, 1977. 14 Norris M. Integration ofspecial hospital patients into the community. Aldershot: Gower, 1984. 15 Bailey J, MacCulloch MJ. Patterns of reconviction in patients discharged directly to the community from a special hospital: implications for aftercare. J7ournal of Forensic Psychiatry (in press). 16 Rice ME, Quinsey VC, Harris GT. Sexual recidivism among child molesters released from a maximum security institution. J Consult Clin Psychol 1991;3:381-6. 17 Copas JB, Whitely JS. Predicting success in the treatment of psychopaths. Br J Psychiatry 1976;129:388-92. 18 Grounds AT, Quayle MT, France J, Brett T, Cox M, Hamilton JR. A unit for "psychopathic disorder" patients in Broadmoor hospital. Med Sci Law 1987;27:21-31. 19 Department of Health, Home Office. Review of health and social services for mentallv disordered offenders and others requiring similar services. London: Department of Health, Home Office, 1991. 20 Home Office, Department of Health and Social Security. Report of the committee on mentally abnormal offenders. London: HMSO, 1975. (Butler report; Cmnd 6244.) 21 Chiswick D. What mentally ill offenders need. BMJ 1992;304:267-8. 22 Mawson D. Psychopaths in special hospitals. Bulletin of the Royal College of Psychiatrists 1983;7:178-8 1.
The future of primary health care From the margins to the mainstream National initiatives to develop primary care and increase its influence on secondary care have proliferated recently."3 Together with a series of influential policy discussion documents"7 these aim at profound and interrelated changes in the content, emphasis, and organisation of primary care. The transfer of strategic management responsibility for primary care from the Department of Health to regional health authorities just over a year ago was part of this. By necessity, regional health authorities started tackling the most urgent topics first, which included fundholding and learning the business of family health services authorities. Responsible for both family health services authorities and district health authorities, regions also have a wider role in ensuring effective joint purchasing of primary and secondary care and the provision of an integrated service. North East Thames's Pnmary Health Care in the 1990s-A Strategic Statement is a positive first step.6 A clear statement of the regional health authorities' commitment to primary care, it will help to develop a shared understanding of needs and priorities. It establishes the essential interdependence of primary and secondary care and through wide consultation will already have started some of the difficult discussions about issues such as quality and resources. 1582
The strategy identifies opportunities to develop a more effective system of primary care. Primary care must be seen as a core part of an improved health service, not just as a gateway to another part of the service. North East Thames will spend at least £2-1 billion on primary care over the next five years. The strategy emphasises health promotion and prevention among patients and working towards goals with measurable outcomes. Rising expectations among patients and the need for a better dialogue between users and service providers are recognised. The report refers to the changing range of services available in primary care and the increasing focus on day case surgery in hospitals. Changes in national policy have meant that general practitioners and family health services authorities have made considerable progress in changing patterns of service. The strategy, however, emphasises the need for both sustained investment of resources and targeting attention at deprived areas of the "outer city" which have so far been neglected. It concludes by identifying the need for developing professional education and training and promoting innovation, good practice, and more flexible budgeting. Although it has strengths, the strategy is not without its problems. Firstly, it predicts an exponential pace for practice BMJ VOLUME 304
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